Antithrombotic therapy in patients with acute coronary syndromes: a balance between protection from ischemic events and risk of bleeding

Platelet activation plays a primary role in the pathogenesis of acute coronary syndromes (ACS); thus, anti-thrombotic therapy with aspirin and clopidogrel represents the mainstay of treatment in those patients. However, low clopidogrel response has become a contemporary issue in interventional cardiology, increasing the risk of ischemic events and significantly worsening short- and long-term prognosis after coronary stenting. Alternative approaches to overcome this phenomenon have been investigated as well as increase in the loading and maintenance clopidogrel doses, reloading patients already on chronic therapy, use of newer and more effective antiplatelet agents. Otherwise a more aggressive antiplatelet treatment may lead to possible increase in bleeding complications. A strategy of an individualized antiplatelet therapy according to point-of-care platelet function tests may represent the optimal approach to balance both ischemic and hemorrhagic risk.